A client, who was a victim of intimate partner abuse, is experiencing anxiety and is crying. What should the nurse do?

Allow the client some time to gather her thoughts.

Remain with the client.

Make an audio recording of this.

Tell the client to write down her thoughts.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Allowing the client some time alone could be beneficial in certain situations where the client prefers solitude to process their emotions. However, in the context of intimate partner abuse, leaving the client alone when they are visibly distressed may not provide the immediate support and safety they need.

Choice B reason:
Remaining with the client is crucial in providing emotional support and ensuring their safety. Victims of intimate partner abuse often feel isolated and scared; having a compassionate presence can offer comfort and reassurance. The nurse's presence can also help in assessing the client's immediate needs and risks, and in facilitating access to further support and resources.

Choice C reason:
Making an audio recording without the client's consent could be a violation of privacy and trust. It is essential to respect the client's autonomy and confidentiality, especially in sensitive situations involving abuse. The priority should be to address the client's emotional state and safety, not to gather evidence.

Choice D reason:
Encouraging the client to write down their thoughts can be a therapeutic tool and may be suggested as part of ongoing therapy or coping strategies. However, it should not be the first action taken when the client is in acute distress. Immediate emotional support and safety planning are more pressing concerns.

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Correct Answer is C

Explanation

Choice A Reason
While hypertension can contribute to the development of PAD, it does not directly cause fats to deposit in the arteries. Hypertension can damage the arterial walls, making them more susceptible to atherosclerosis, but it is not the primary mechanism of PAD development.

Choice B Reason
Excess fats in the diet can contribute to atherosclerosis, which is the accumulation of plaques in the arterial walls. However, the fats do not simply get stored; they combine with other substances, including calcium and inflammatory cells, to form plaques that can restrict blood flow.

Choice C Reason
This statement is the most accurate. PAD is primarily caused by atherosclerosis, which is the buildup of plaques formed by fats, cholesterol, calcium, and other substances in the blood. These plaques can harden and narrow the arteries, leading to reduced blood flow to the extremities. The process can be exacerbated by factors such as smoking, diabetes, and high cholesterol.

Arterial spasms can occur, but they are not the typical cause of chronic PAD. Spasms are more often associated with conditions like Raynaud's phenomenon or can be a response to stress or cold temperatures. PAD is usually a result of progressive atherosclerosis rather than intermittent spasms.

A. displays hypervigilance and refuses to attend unit activities. B. is flirtatious toward staff members of the opposite sex. C. urges a suspicious client to hit anyone who stares at him. D. clings to the nurse and asks for advice about inconsequential matters.

Correct Answer is C

Explanation

Choice A Reason
Limit setting may be helpful for a client who displays hypervigilance and refuses to attend unit activities, as it can provide clear expectations and help reduce anxiety. However, this behavior does not pose an immediate risk to the safety of others, making limit setting less essential compared to behaviors that could lead to harm.

Choice B Reason
While being flirtatious toward staff members may be inappropriate and require intervention, it is typically addressed through professional boundaries rather than limit setting. Limit setting in this context would involve clarifying acceptable behaviors within the therapeutic relationship.

Choice C Reason
Urging another client to commit violence is a behavior that necessitates immediate limit setting. This behavior poses a direct threat to the safety of others and disrupts the therapeutic environment. Limit setting here would involve immediate intervention to prevent harm and to maintain a safe environment for all clients.

Choice D Reason
A client who clings to the nurse and seeks advice on inconsequential matters may benefit from limit setting to encourage independence and appropriate use of staff time. However, this behavior is not as disruptive or dangerous as inciting violence, making it a lower priority for limit setting.

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A client, who was a victim of intimate partner abuse, is experiencing anxiety and is crying. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic peripheral arterial disease (PAD) asks the nurse why this disease developed. Which explanation by the nurse is most accurate?

Correct Answer is C

Explanation

For which of the following behaviors would limit setting be most essential? The client:

Correct Answer is C

Explanation

The nurse is providing discharge teaching to a client newly diagnosed with hypertension. Which food item(s) should the nurse instruct the client to avoid in order to assist In controlling the blood pressure? (SELECT ALL THAT APPLY)

The nurse would include which teaching or intervention in the care plan of a client experiencing diarrhea related to antibiotic therapy?

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